Saturday, April 3, 2010

April is Cesarean Awareness Month.
Can you imagine driving 3 hours to see your obstetrician or midwife for prenatal visits? Can you imagine feeling your first sensations of labor and driving that long? Can you imagine driving home with a newborn in the car and sitting on a donut for 3 hours?

I am working with women who are driving from all parts of Iowa to work with the Univesity of Iowa Hospitals and Clinics (UIHC) certified nurse midwives (CNMs) and obstetricians. The sad part is that they are forced to seek care so far from home. The great part is that the UIHC CNMs welcome VBAC patients and are great advocates for VBAC awareness and primary cesarean prevention.

The National Center for Health Statistics reported last month that the cesarean or c-section rate hit an all-time high in 2007, with a rate of 31.8 percent, up 2 percent from 2006.

When a cesarean is medically necessary, it can be a lifesaving technique for both mother and baby, and worth the risks involved. However, a vaginal birth is still considered the safest birth for a woman and her baby. Marygrace Elson, MD, director of general gynecology in the Women's Health Center at University of Iowa Hospitals and Clinics, talks about c-sections:

Why are the number of caesarian births on the rise?

As you mentioned, the total cesarean rate in the U.S. is now at about 32 percent. That's about doubled over the last 20 years. Operative deliveries have stayed right at about 9 percent. Here at UI Hospitals and Clinics, our rate is right at the national average, right around 32 percent.

These rates are impacted by several factors. The medical-legal climate in the United States certainly looms large for anyone providing obstetric care, because if there's a poor outcome with the baby, the plaintiff's attorney will argue that either one should have done a c-section, or, if you did, they will argue it should have been done sooner.

We're also starting to see women request elective cesarean births. It's estimated that about 2.5 percent of all births in the United States now are c-sections on maternal request. There are lots of motivations for this request. Sometimes families simply like the idea of picking a day for logistical reasons. The only real medical reason to consider elective cesarean has to do with pelvic support.

There's absolutely no question that having a baby weakens a woman's pelvic floor and this can lead to later problems with urinary incontinence or prolapse. Aside from a longer hospital stay and the other things we've already discussed, elective cesarean birth after 39 completed weeks is not a very big deal the first time around. The real issue of elected cesarean birth shows up with the next pregnancy because any time there's a scar in the uterus, the placenta may implant in the wrong place; for example, in front of the baby and this sets women up for hemorrhage and possible need for hysterectomy.
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What bottom line advice would you give to pregnant women who are considering their birthing options?

Women should discuss their questions and concerns with the provider taking care of them during the pregnancy, including pain relief in labor and what the provider's philosophy is about interventions in labor and birth.

Together, they should discuss her risk factors and what the provider's recommendations are for birth route. This discussion should take into account the woman's age, her history, her future pregnancy plans. Both the woman and the provider should be on the same page. If a woman has had a prior cesarean birth and wants a trial labor, and if she's a good candidate but her local hospital cannot offer her this option, we would always be happy to see her in consultation in University of Iowa Hospitals and consider co-managing with her local provider.
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